Coupling device for coupling a rod to a bone anchor

ABSTRACT

A coupling device for coupling a rod to a bone anchor includes a receiving part having a central axis, a coaxial passage, and an engagement recess extending laterally into the passage, and a pressure member having an expandable portion to clamp the head, a radially outwardly facing surface, and an engagement surface extending from the radially outwardly facing surface. The engagement surface of the pressure member is recessed from an outer surface of the receiving part. The pressure member is movable axially from a first position towards a second position where the receiving part directly engages the pressure member to increase a compression force on the expandable portion for clamping an inserted head. The engagement surface of the pressure member is engageable through the engagement recess of the receiving part by the instrument to move the pressure member axially from the second position back towards the first position.

CROSS-REFERENCE TO RELATED APPLICATION(S)

This application is a continuation of U.S. patent application Ser. No.17/111,100, filed Dec. 3, 2020, which claims priority to and the benefitof U.S. Provisional Patent Application No. 62/944,592, filed Dec. 6,2019, the contents of which are hereby incorporated by reference intheir entirety, and claims priority from European Patent Application EP19 214 198.4, filed Dec. 6, 2019, the contents of which are herebyincorporated by reference in their entirety.

BACKGROUND Field

The application relates to a coupling device for coupling a rod to abone anchor, and more particularly relates to a polyaxial bone anchoringdevice, wherein a head of the bone anchor can be provisionally lockedwith respect to the coupling device and can be unlocked from such aprovisional locking configuration. The invention also relates to asystem including the coupling device or the polyaxial bone anchoringdevice and an instrument.

Description of Related Art

U.S. Pat. No. 5,672,176 describes an anchoring member for connecting arod with a bone screw, that includes a screw member and a seat partreceiving a screw head of the screw member and a rod. The anchoringmember further includes a pressure member formed to embrace the screwhead. The seat part has a tapering portion and the pressure member hasan outer conical surface in a region laterally surrounding the screwhead. The conical surface tapers with a cone angle corresponding to thecone angle of the surface of the seat part. When the conical surfacesengage each other, a movement of the screw head is blocked even if aswivel nut is loosened for readjusting the rod.

A polyaxial bone anchoring device with a function of pre-locking a headof a bone anchor is known, for example, from U.S. Pat. No. 8,926,671 B2.The polyaxial bone anchoring device includes a receiving part includinga receiving part body with a channel for receiving a rod and anaccommodation space for accommodating the head of the bone anchor, and apressure element arranged at least partially in the accommodation space.The pressure element has a flexible portion to clamp the head and canassume a pre-locking position to clamp the head in the receiving part bya pre-stress exerted by the pressure element onto the head. In thepre-locking position, an outer surface portion of the pressure elementand an inner surface portion of the receiving part body are engaged. Inone example, the surfaces can be tapered. Locking of the head isachieved via a locking member.

U.S. Pat. No. 9,345,516 B2 describes a polyaxial bone anchoring device,wherein a temporary clamping of a head of an anchoring element in adesired angular position with respect to a receiving part withoutlocking the head can be achieved. The polyaxial bone anchoring deviceincludes a set screw that is threadable into a through hole of thereceiving part and that engages a hole in the pressure element such thata force is exerted by the pressure element onto the head that maintainsthe head at an adjustable angular position.

SUMMARY

While the known polyaxial bone anchoring devices exhibit some aspects oflocking or provisionally locking the head of the bone anchor whileallowing correction steps to be carried out, there is still a need for apolyaxial bone anchoring device that provides more options for carryingout correction steps during surgery more easily and/or repeatedly.

It is therefore an object of the invention to provide an improvedcoupling device for a polyaxial bone anchoring device, the polyaxialbone anchoring device, and a system including such a coupling device orpolyaxial bone anchoring device and an instrument.

According to an embodiment, a coupling device for coupling a rod to abone anchor includes a receiving part having a channel for receiving arod, a passage defining a central axis, and an accommodation space for ahead of the bone anchor. The receiving part includes an outer surfacewith an engagement structure configured to be engaged by an instrument.The coupling device further includes a pressure member configured to bearranged at least partially in the accommodation space. The pressuremember has a flexible portion defining a hollow interior to accommodateand clamp the head therein and an outer surface with an engagementstructure configured to be engaged by the instrument. In the receivingpart, the pressure member can assume a first position in which aninserted head is clamped or locked with a first locking force or isfreely pivotable, and a second position in which the pressure memberengages an inner wall portion of the passage such that the flexibleportion is compressed to clamp or lock an inserted head with a lockingforce that is greater than the first locking force, and wherein thepressure member is movable from the second position back towards thefirst position by engagement with the instrument.

The coupling device permits easy unlocking of an inserted head. Also, aclamping and/or locking step and an unlocking step can be carried outrepeatedly. The clamping or locking step can be carried out easily, forexample, using a rod inserted into the channel and/or a locking member.For the unlocking step, the instrument may be used. The instrument worksreliably in any situation or level of locking, such as full locking ofthe head or only frictional clamping of the head.

The instrument is configured to laterally engage the pressure member.Therefore, the unlocking step can be effected when the rod is not in thechannel or when the rod is at an elevated position relative to a bottomof the channel.

With the instrument and the coupling device, the unlocking step can beprecisely carried out, as the forces that are necessary for unlockingare automatically generated due to the geometry and position of thepressure member relative to the receiving part.

In a specific embodiment, engagement structures for the instrument thatare provided at the pressure member and the receiving part,respectively, may be offset from each other in an axial direction. Thisleads to an automatic centering and/or aligning of the respectiveengagement structures when the instrument successively engages theengagement structure of the receiving part and the engagement structureof the pressure member.

The polyaxial bone anchoring device is preferably of the bottom-loadingtype, which means that the head of the bone anchor is inserted from abottom opening of the receiving part into the accommodation space.Hence, a modular system can be provided where any type of bone anchorthat has a head can be combined with the coupling device to provide apolyaxial bone anchoring device.

A particular application of the coupling device, the polyaxial boneanchoring device, and the system including the coupling device or thepolyaxial bone anchoring device and the instrument may be in the fieldof spinal surgery.

BRIEF DESCRIPTION OF THE DRAWINGS

Further features and advantages of the invention will become apparentfrom the description of embodiments by means of the accompanyingdrawings. In the drawings:

FIG. 1 shows an exploded perspective view of a polyaxial bone anchoringdevice according to an embodiment.

FIG. 2 shows the polyaxial bone anchoring device of FIG. 1 in anassembled state.

FIG. 3 shows a perspective view of a system including the polyaxial boneanchoring device of FIGS. 1 and 2 and an instrument.

FIG. 4 shows a cross-sectional view of the polyaxial bone anchoringdevice of FIGS. 1 to 3, the cross-section taken in a plane including acentral longitudinal axis of a receiving part of the polyaxial boneanchoring device and perpendicular to a longitudinal axis of a rodchannel of the receiving part.

FIG. 5 shows a perspective view from a top of the receiving part of thepolyaxial bone anchoring device of FIGS. 1 to 4.

FIG. 6 shows a perspective view from a bottom of the receiving part ofFIG. 5.

FIG. 7 shows a top view of the receiving part of FIGS. 5 and 6.

FIG. 8 shows a cross-sectional view of the receiving part of FIGS. 5 to7, the cross-section taken along line A-A in FIG. 7.

FIG. 9 shows a perspective view from a top of a pressure member of thepolyaxial bone anchoring device of FIGS. 1 to 4.

FIG. 10 shows a perspective view from a bottom of the pressure member ofFIG. 9.

FIG. 11 shows a top view of the pressure member of FIGS. 9 and 10.

FIG. 12 shows a cross-sectional view of the pressure member of FIGS. 9to 11, the cross-section taken along line B-B in FIG. 11.

FIG. 13 shows a perspective view of the instrument of FIG. 3, seen froma side opposite to the side shown in FIG. 3.

FIG. 14 shows a perspective view from a bottom of a front portion of theinstrument of FIGS. 3 and 13.

FIG. 15 shows a perspective view from a top of the front portion of theinstrument of FIGS. 3, 13, and 14.

FIG. 16 shows a cross-sectional view of the front portion of theinstrument of FIGS. 3 and 13 to 15, where the cross-section is taken ina plane containing a central longitudinal axis of the instrument andextending through centers of two end portions of the instrument.

FIGS. 17a to 17c show steps of mounting a coupling device of thepolyaxial bone anchoring device of FIGS. 1 to 4 onto a bone anchor thathas been inserted into bone.

FIGS. 18a to 18c show steps of locking the bone anchor relative to thecoupling device with a locking member and then loosening the lockingmember.

FIGS. 19a to 19c show steps of unlocking a head of the bone anchorrelative to the coupling device using the instrument of FIGS. 3 and 13to 16.

FIG. 20 shows a perspective view of a polyaxial bone anchoring devicewith a coupling device according to another embodiment.

DETAILED DESCRIPTION

A polyaxial bone anchoring device according an embodiment is generallyshown in FIGS. 1 to 3, and includes a bone anchoring element 1 in theform of a screw member having a shank 2 which is at least partiallythreaded and a head 3. The head 3 has a spherical outer surface portion.In greater detail, in the embodiment, the head 3 is shaped as aspherical segment with a substantially flat end surface in which arecess 4 for engagement with a tool may be provided. The bone anchoringdevice further includes a coupling device for connecting the boneanchoring element 1 to a rod 100. The coupling device includes areceiving part 5 and a pressure member 6 that is configured to bearranged in the receiving part 5 and is further configured to exertpressure onto the head 3. In addition, for securing the rod 100 in thereceiving part 5 and for exerting pressure onto the rod 100 and thepressure member 6, a locking member 7 in the form of, for example, a setscrew which cooperates with the receiving part 5 may be provided. Thelocking member 7 may have a tool engagement recess 7 a. The pressuremember 6 may be secured and/or aligned in the receiving part by means ofa securing element, for example, by pins 8.

As shown in FIG. 3, an embodiment of a system includes the polyaxialbone anchoring device as shown in FIGS. 1 and 2 and an instrument 200.The instrument 200 is configured to engage the receiving part 5 and thepressure member 6 to move the pressure member 6 relative to thereceiving part 5.

As illustrated in particular in FIGS. 5 to 8, the receiving part 5 issubstantially cylindrical and has a first end or top end 5 a, a secondend or bottom end 5 b, and a passage 51 extending from the top end 5 atowards the bottom end 5 b, the passage defining a longitudinal centralaxis C. The passage 51 extends completely from the top end 5 a to thebottom end 5 b, thereby forming an opening 52 at the bottom end 5 b.Adjacent to the top end 5 a, a substantially U-shaped recess 53 isprovided that extends towards the second end 5 b to a bottom 53 a. Thepassage 51 may have sections with different diameters. In the embodimentshown, a first section 51 a may have a substantially constant diameterand extends from the top end 5 a to an axial height above orcorresponding approximately to the height of the bottom 53 a of theU-shaped recess 53. Below the first section 51 a, a second section 51 cmay be provided that narrows towards the bottom end 5 b. In greaterdetail, in the embodiment, the second section 51 c tapers, preferablyconically, towards the bottom end 5 b. Within the second section 51 c, awidened section 51 b is formed that widens towards the bottom end 5 b.Hence, the narrowing regions of the second section 51 c are divided intoa portion above the widened section 51 b and a portion below the widenedsection 51 b. The widened section 51 b provides an accommodation spacefor a portion of the pressure member 6 which can expand therein. Thedifference in diameter between the widened section 51 b and the secondsection 51 c forms an edge 51 d that protrudes into the passage 51. Thesubstantially U-shaped recess 53 divides the upper portion of thereceiving part 5 into two free legs 54 and forms a channel for receivingthe rod. An internal thread 55, for example, a square thread, may beformed on an inner wall portion of the legs 54, preferably adjacent tothe top end 5 a, for cooperating with the locking member 7. An axiallength of the tapered second section 51 c may be such that, incooperation with the pressure member 6, a locking force may be generatedthat is configured to compress a portion of the pressure member forfrictionally clamping and/or firmly locking the head 3 in the pressuremember 6.

At a distance above the bottom 53 a of the U-shaped recess, two oppositetransverse holes 56 extend completely through the wall of the receivingpart 5. The transverse holes 56 are configured to receive the pins 8.

The receiving part 5 further includes at least one, two in theembodiment shown, engagement structures 57 for engagement with theinstrument 200. The engagement structures 57 are formed as narrowingholes or bores extending completely from an outer surface of thereceiving part through a wall of the receiving part into the passage 51.The engagement structures 57 may narrow in a conical shape which tapersand narrows from outside the receiving part towards the passage.Preferably, the shape of each engagement structure is substantially thatof a hollow truncated cone. Two such holes may be provided 180° offsetfrom each other in a circumferential direction around the central axisC. In this embodiment, the engagement structures 57 extend in adirection perpendicular to a plane including a channel axis L of theU-shaped recess 53 and the central longitudinal axis C. Morespecifically each engagement structure 57 has a central transverse holeaxis a that extends perpendicular to the central axis C. Moreover, theengagement structures 57, or more specifically the hole axes a, are atan axial position Ha with respect to the bottom end 5 b. The holes maybe symmetrical around the hole axis a. The axial height Ha may be suchthat the hole axis a is above the bottom 53 a of the U-shaped recess 53,and preferably the hole axis a may be at least partially within thesecond section 51 c, or in other words, in a narrowing section of thepassage 51. An inner size of the engagement structure 57 is such that afront portion of the instrument 200 can be received therein in asubstantially form-fit manner, as discussed in greater detail below.Hence an inner wall of the engagement structures 57 form guidingsurfaces, respectively, for a portion of the instrument.

Finally, at the same circumferential position as the engagementstructures 57 and in an axial position closer to the top end 5 a, toolengagement recesses 58 may be formed in the outer surface of thereceiving part 5. The tool engagement recesses 58 may have, for example,a circular contour.

Referring now to FIGS. 9 to 12 the pressure member 6 will be describedin greater detail. In the embodiment, the pressure member 6 is amonolithic part. The pressure member 6 has a first end or upper end 6 aand an opposite or lower end 6 b. Adjacent to the upper end 6 a, thepressure member 6 has a substantially cylindrical outer shape with anouter diameter only slightly smaller than an inner diameter of the firstsection 51 a of the passage 51, such that the cylindrical portion of apressure member fits into the first section 51 a and can move or slidetherein. Adjacent to the upper end 6 a, a substantially V-shaped recess61 for the rod 100 is provided. More specifically, a base 61 a of therecess 61 has a substantially V-shaped contour. Thereby rods 100 ofdifferent diameter can selectively be supported on the base 61 a. Suchrods (not shown) rest on the base 61 a along substantially twolongitudinal contact lines. A rod that is supported in this manner maybe prevented from moving sideways. Sidewalls of the recess 61 may besubstantially vertical, and the deepest portion of the base 61 a may berounded. By means of the V-shaped recess 61, upstanding legs 62 areformed which may have a height, or in other words, the substantiallyV-shaped recess 61 may have a depth, such that the top end 6 a of thepressure member is below a highest point of an outer surface of aninserted rod 100 when the rod rests on the base 61 a.

The lower portion of the pressure member 6 has a narrowing outer surface63 that narrows towards the bottom end 6 b. More specifically, thesurface 63 is a conical outer surface that tapers towards the bottom end6 b. The outer surface 63 is configured to cooperate with the narrowingsecond section 51 c of the passage 51 of the receiving part 5. Adjacentto the bottom end 6 b, there is a hollow interior section 64 foraccommodating the head. The hollow interior section 64 may havesubstantially spherically-shaped sections 64 a that match the sphericalshape of the outer surface portion of the head 3 and a slightly enlargedsection 64 b to facilitate pivoting of the head. The hollow interiorsection 64 has an opening 65 at the bottom end 6 b. A plurality of slits66 which are open towards the bottom end 6 b extend in an axialdirection along the wall of the pressure member 6 in the region of thehollow interior section 64. A length of the slits 66 in the longitudinaldirection may be such that, when the head 3 is inserted, the slitsextend above a region of the head 3 with a greatest outer width.Further, the slits 66 may each have a widened end portion 66 a to renderthe lower portion of the pressure member 6 more flexible, in a mannersuch that the lower portion can be expanded and compressed. Hence, thelower portion of the pressure member forms a flexible portion. The sizeof the hollow interior 64 may be such that when the head 3 is insertedthrough the opening 65, the flexible portion snaps onto the head andslightly clamps the head 3 by friction.

For providing access to the tool engagement recess 4 of the head 3, thepressure member 6 defines a coaxial bore 67. The coaxial bore 67 mayextend from the substantially V-shaped recess 61 into the hollowinterior section 64.

In addition, the pressure member 6 includes at least one engagementstructure, with two opposite engagement structures 68 in the embodimentshown. The engagement structures 68 are configured to be engaged by afront portion of the instrument 200. In greater detail, the engagementstructures 68 in the embodiment are formed as conical holes or boresthat extend through the wall of the pressure member 6 from the outsideto the coaxial bore 67. A transverse central axis b of the holes may belocated at an axial position slightly below the deepest portion of thebase 61 a of the substantially V-shaped recess 61. More specifically,the axial position of the engagement structures 68 is at least partiallywithin the narrowing outer surface 63. The transverse central axes b ofthe engagement structures 68, respectively, extend substantiallyperpendicularly to the longitudinal L defined by the recess 61.

A diameter of the holes at the outer surface of the pressure member 6substantially corresponds to a diameter of the holes at the receivingpart 5 at a location of the passage. Hence, when the pressure member 6is in the receiving part 5 at an axial position where the axes a of theholes in the receiving part 5 and the axes b of the holes in thepressure member 6 are at a same height, the holes of the receiving part5 generally align with and are substantially flush with the holes of thepressure member 6, forming a continuous hollow space, preferably ahollow cone.

Moreover, the pressure member defines two elongate recesses 69 in thecenter of each of the legs 62 which are opposite to each other and arealigned such that a longer side of the elongate recesses 69 issubstantially parallel to the central axis C of the receiving part 5.The ends of the elongate recesses 69 may be rounded. A width and lengthof the elongate recesses 69 is such that the pins 8 can be receivedtherein and moved in the axial direction.

Turning back to FIG. 4, the dimensions of the pressure member 6 and thedimensions of the receiving part 5 are selected such that when thepressure member 6 is in the receiving part 5, the head 3 is insertedinto the hollow interior section 64 of the pressure member and thenarrowing surfaces of the second section 51 c of the receiving part andthe narrowing outer surface 63 of the pressure member 6 are engaged tosome extent, the head 3 is clamped or firmly locked depending on theextent of the engagement. It shall be noted that the narrowing,preferably conical, shape of the pressure member that extends along atleast the axial length of the flexible portion and that cooperates withthe narrowing, preferably conical, second section 51 c in the receivingpart over an axial length greater than a length of the flexible sectionsresults in a reliable or strong clamping of the head. As shown in FIG.4, the engagement structures 68 of the pressure member 6 and theengagement structures 57 of the receiving part 5 are offset from eachother in the axial direction. In greater detail, the engagementstructure 57 of the receiving part is at a slightly higher axialposition Ha compared to the position H_(b) of the engagement structure68 of the pressure member 6. This defines a position of the pressuremember relative to the receiving part in which the head 3 is clamped andcan be pivoted only by overcoming a friction force, or may even be fullylocked.

Referring now to FIGS. 13 to 16, the instrument 200 may be implementedas a hand-held instrument in the form of tongs having a pair of handles201 at one end and a pair of claws 202 forming a front portion at anopposite end. Between the handles 201 and the claws 202, two pairs oflevers are arranged (see also FIG. 3). A first pair of levers 203 isconfigured to pivot around a pivot axis 203 a and are connected at oneside to the handles 201, respectively, and at an opposite side to asecond pair of levers 204. The second pair of levers 204 is configuredto pivot around a pivot axis 204 a. The second pair of levers 204 isconnected to the first pair of levers 203 through pivots or hinges 205and is connected at an opposite end to the claws 202. By means of this,the claw on one side is connected to the handle on the same side and theclaw on the other side is connected to the handle on the other side.With this construction, moving of the handles 201 towards one anothercauses the claws 202 to move towards each other as well, thereby beingaligned to be substantially parallel. The instrument may include aspring 206 that holds the claws 202 in an open position, the springforce of which must be overcome by the handles 201 to close the claws202.

As shown in greater detail in FIGS. 14 to 16, a front portion of theinstrument 200 includes the claws 202. The claws 202 are configured toengage the receiving part 5 from an outside thereof. To accomplish this,the claws 202 each defines a cylindrical recess 221 adjacent to a frontend 200 a, which is adapted or shaped to correspond to the outer shapeof the receiving part 5. Adjacent to the front end 200 a, at an innerwall of the cylindrical recesses 221, an engagement structure 222 isprovided. The engagement structure 222 is configured to engageengagement structure 57 at the receiving part and the engagementstructure 68 at the pressure member 6. Specifically, the engagementstructure 222 may be a conical peg that is adapted or shaped tocorrespond to the hollow conical shape of the conical holes of thereceiving part and the pressure member. To accomplish this, theengagement structure 222 is located at approximately the center of eachclaw 202 in the circumferential direction. Adjacent to the cylindricalrecess 221 on a side opposite the front end 200 a, the claws 202 maydefine a further cylindrical recess 224. The cylindrical recess 224 mayhave a smaller diameter than the cylindrical recess 221. Duringengagement of the claws with the receiving part, the second cylindricalrecess 224 may provide space for accommodating a portion of the lockingmember 7 therein.

The locking member 7 may have a projection 7 b at a bottom side thereof(see FIG. 1) that serves for elongating the locking member 7, to permitthe fixation of rods of smaller and greater diameters in the rodreceiving recess 53 using the same locking member. Hence, when a rod ofgreater diameter is received, the locking member 7 may protrude out ofthe first end 5 a of the receiving part 5.

The parts and portions of the bone anchoring device and the instrumentmay be made of any material, preferably, however, of a bio-compatiblematerial, such as for example, titanium or stainless steel, or any otherbio-compatible metal or metal alloy, for example, or a plastic material.For a bio-compatible alloy, a NiTi alloy, for example Nitinol, may beused. Other materials that can be used may be magnesium or magnesiumalloys. Bio-compatible plastic materials for use may be, for example,polyether ether ketone (PEEK) or poly-L-lactide acid (PLLA). The partscan be made of the same or of different materials from one another.

In use, at least two bone anchoring devices may be anchored in bone andconnected through a rod. As the bone anchoring device according to theembodiment described is a bottom-loading bone anchoring device, the headof the bone anchor 1 is inserted from the bottom end 5 b into thereceiving part. This can be done prior to insertion of the shank intothe bone. Alternatively, the shank can already be inserted into avertebra or other bone, and the coupling device can then be mounted ontothe head 3.

Referring to FIGS. 17a to 17c , steps for mounting the coupling deviceto the bone anchor are shown. The bone anchor 1 has been inserted intobone 500, where the head 3 protrudes out of the bone surface. Thecoupling device may be preassem bled, where the pressure member has beeninserted into the passage to an extent such that the flexible portion islocated in the widened section 51 b of the passage 51 that forms anaccommodation space. The pins 8 are placed in the holes 56, where theirfront ends extend into the recesses 69 of the pressure member 6. Thus,the recess 53 of the receiving part and the recess 61 of the pressuremember are aligned. The rear ends of the pins may be flush with theouter surface of the receiving part. As depicted in FIG. 17a , thepressure member 6 is at a highest position relative to the bottom end 5b of the receiving part 5. This highest position defines an insertionposition where the head 3 can be inserted. In the insertion position thelower ends of the recesses 69 of the pressure member 6 abut against theinserted pins 8. The engagement structure 68 of the pressure member isat an axial height H_(b) that is above an axial height Ha of theengagement structure 57 of the receiving part 5 relative to the bottomend 5 b. As depicted in FIG. 17b , the coupling device is placed ontothe head 3. The pins 8 serve as abutment for the pressure member 6. Whenthe head 3 enters into the hollow interior 64, the flexible portion canexpand in the accommodation space 51 b. Finally, as shown in FIG. 17c ,the coupling device is pulled upwards relative to the head 3. As thehead 3 is clamped in the flexible portion of the pressure member, thereceiving part 5 is moved slightly upwards so that the narrowing surfacein the second section 51 c of the passage 51 and the narrowing surface63 at the outside of the pressure member engage. Thereby, the head 3 isclamped by friction and can pivot only by overcoming the friction force.Simultaneously, the head 3 can no longer escape through the loweropening 52 of the receiving part 5, since the bottom of the pressuremember blocks the head 3 from doing so.

Referring to FIGS. 18a and 18b , steps of locking the polyaxial boneanchoring device are shown. In FIG. 18a , the rod 100 is inserted andthe locking member 7 is screwed in between the legs 54 of the receivingpart 5. Tightening the locking member 7 results in a pressure exertedthrough the rod onto the pressure member 6. Thereby, the pressure member6 is pushed deeper towards the bottom end 5 b, with the narrowing outersurface 63 of the flexible portion being urged deeper into the narrowingsecond section 51 c of the passage. This results in a compression of theflexible portion of the pressure member around the head 3, which locksthe head 3 in the receiving part 5 and holds the shank 2 at a specificangular position relative to the central axis C. As shown in FIG. 18b ,unscrewing or removing the locking member 7 allows the rod 100 to moveup in an axial direction and/or to be removed completely from thereceiving part. For example, the rod 100 can assume an axial positionabove the base 61 a so that it no longer rests on the base 61 a. Hence,various correction steps can be carried out with the rod not beingpresent at all or being at an elevated position in the channel. When thehead 3 is locked or provisionally locked, the engagement structure 68 ofthe pressure member 6 is moved downward relative to the engagementstructure 57 of the receiving part 5. In the embodiment, in the lockedor provisionally locked configuration, the axial position of theengagement structure 57 of the receiving part 5 is higher than the axialposition of the engagement structure 68 of the pressure member 5. Hence,in the locked or provisionally locked configuration, the engagementstructures of receiving part and pressure member are offset from eachother in a way such that bringing them into alignment with each otherresults in unlocking of the head 3, for example, by moving the pressuremember axially upwards.

Next, as shown in FIG. 18c , the claws 202 are moved in an open statetowards the receiving part 5 and oriented such that the pegs 222 arecircumferentially aligned with the engagement structure 57 of thereceiving part.

FIG. 19a shows that the pegs 222 of the claws 202 engage the engagementstructure 57 of the receiving part. The rod 100 may be at an elevatedposition, and the locking member 7 may protrude into the cylindricalrecess 224. As shown in FIGS. 19a and 19b , actuating the handles 201 ofthe instrument 200 moves the claws from both sides inwardly towards thecentral axis, while for example, the claws may remain substantiallyparallel with one another. The pegs 222 extend through the holes of thereceiving part 5 and enter into the holes of the pressure member 6.Because of the offset of the axial position of the hole axes (e.g.,where the holes of the pressure member 6 are below the holes of thereceiving part 5), an upper front edge portion 222 a of the pegs 222abuts against an upper wall of the hole of the pressure member 6 asdepicted in the enlarged portion of FIG. 19b . Thus, the upper wall ofthe engagement structure 68 of the pressure member 6 forms a guidingsurface for guiding the engagement portion 222 of the instrument.

Finally, as shown in FIG. 19c , the engagement of the engagementstructure 57 at the pressure member with the engagement portion 222 ofthe instrument leads to alignment of the engagement structures of thereceiving part and the pressure member, as depicted in greater detail inthe enlarged portion of FIG. 19c . Thereby, a force is generated thatmoves the pressure member 6 upward relative to the receiving part 5 to aposition in which the engagement structures are aligned. When thepressure member is moved upwards, the compression of the head 3 isdecreased and the head is unlocked. It shall be noted that, depending onthe dimensions of the pressure member and the receiving part, the headcan be completely freely pivotable when unlocked, or may still be heldby friction so that the shank can be maintained provisionally at adesired angular position. This position can be changed by overcoming thefriction force.

Another embodiment of the polyaxial bone anchoring device is shown inFIG. 20. The coupling device differs from the coupling device describedin the previous embodiment by the design of the receiving part and thepressure member. The receiving part 5′ and the pressure member 6′include engagement structures 57′ for the receiving part 5′ andengagement structures 68′ for the pressure member 6′ which are offset atan angle different from 90° relative to the longitudinal axis L of therod receiving recess 53. As shown in FIG. 20, the engagement structures57′, 68′ are formed at an angle of 45° or less relative to the rod axisof a rod to be inserted. As in the first embodiment, in each of thereceiving part 5′ and the pressure member 6′, two engagement structures57′, 68′ are provided that are offset by 180° in the circumferentialdirection from one another. Thus, the engagement is effected closer toan inserted rod. Thereby, less space can be used in a directionperpendicular to the rod axis, which may have advantages in certaincases, such as for reducing spreading of a wound or opening duringsurgery. All other features of the polyaxial bone anchoring device areidentical or similar to those of the previous embodiment.

Further modifications of the embodiments described above are alsoconceivable without departing from the spirit and scope of theinvention. For example, the parts are not limited to their detailedshapes as depicted in the embodiments. In particular, the engagementstructures at the receiving part and the pressure member may havedifferent shapes, and the shapes of the engagement structure and theinstrument may also be different. In some embodiments, one engagementstructure on each of the receiving part and the pressure member may besufficient. An instrument with only one engagement portion can be alsosufficient. For the compression of the flexible portion of the pressuremember around the head, the narrowing surface may narrow in anothershape. For example, a combination of a spherical or bulged shape thatabuts against a tapered shape, or a spherical or bulged shape thatengages a hollow spherical or hollow bulged shape may also be possible,or even a combination of two cylindrical surfaces.

For the locking member, other known locking members may be used, forexample, a two-part locking member that permits locking of the head andthe rod separately. The pressure member in this case may have legs thatextend above an uppermost surface of the rod. The base forming the rodsupport surface may also be different, and may for example, be designedto receive only a rod of a single diameter.

The rod used can be any elongate device that is configured to connecttwo bone anchoring devices. The pressure member and/or the receivingpart may also be designed in more than one piece. Also a top loadingpolyaxial bone anchoring device may be implemented, where the boneanchor can be inserted from the top end of the receiving part. Inaddition, for the bone anchor, all kinds of bone anchors can be used,such as screws, nails etc.

While the present invention has been described in connection withcertain exemplary embodiments, it is to be understood that the inventionis not limited to the disclosed embodiments, but is instead intended tocover various modifications and equivalent arrangements included withinthe spirit and scope of the appended claims, and equivalents thereof.

1. A coupling device for coupling a rod to a bone anchor, the couplingdevice comprising: a receiving part having a central axis and defining achannel transverse to the central axis for receiving a rod, a coaxialpassage, an accommodation space for accommodating a head of the boneanchor, and an engagement recess for engagement by an instrument; and apressure member positionable at least partially in the accommodationspace, the pressure member comprising an expandable portion defining ahollow interior to accommodate and clamp the head and an engagementsurface for engagement by the instrument; wherein when the pressuremember is in the receiving part, the engagement surface of the pressuremember is accessible through the engagement recess of the receivingpart, and the pressure member is movable axially from a first positiontowards a second position to increase a compression force on theexpandable portion for clamping an inserted head.
 2. The coupling deviceof claim 1, wherein the expandable portion of the pressure member isflexible.
 3. The coupling device of claim 1, wherein the engagementrecess of the receiving part includes two holes offset from one anotherby 180° around the central axis.
 4. (canceled)
 5. The coupling device ofclaim 1, wherein at least one of the engagement recess of the receivingpart or the engagement surface of the pressure member is inclinedrelative to the central axis.
 6. The coupling device of claim 1, whereinthe engagement recess of the receiving part and the engagement surfaceof the pressure member each comprises a guiding surface for guiding aportion of the instrument, and wherein the respective guiding surfacesare configured to align with one another when the pressure member is atthe first position.
 7. The coupling device of claim 1, wherein thepressure member comprises a substantially cylindrical portion and arecess for receiving the rod.
 8. The coupling device of claim 1, whereinat least part of the expandable portion of the pressure member narrowstowards a free end of the pressure member.
 9. The coupling device ofclaim 8, wherein the engagement surface is formed at least partially inthe narrowing region of the pressure member.
 10. The coupling device ofclaim 8, wherein the passage of the receiving part comprises a narrowingsection configured to cooperate with the narrowing region of thepressure member to compress the expandable portion, and wherein theengagement recess opens at least partially into the narrowing section.11. A bone anchoring device comprising the coupling device of claim 1and the bone anchor comprising a shank for anchoring in bone and thehead, wherein the head has a spherical outer surface portion.
 12. Asystem comprising: a bone anchor comprising a shank for anchoring inbone and a head; a coupling device for coupling a rod to the boneanchor, the coupling device comprising: a receiving part having acentral axis, a channel transverse to the central axis for receiving therod, a coaxial passage, an accommodation space for accommodating a headof the bone anchor, and an engagement recess extending from outside thereceiving part to the passage; and a pressure member positionable atleast partially in the accommodation space to exert pressure on thehead, the pressure member having an engagement surface; wherein when thehead and the pressure member are in the receiving part, the pressuremember is movable axially from a first position towards a secondposition to increase the pressure exerted on the head for clamping thehead; and an instrument comprising an engagement portion configured toengage the engagement recess of the receiving part and to extend throughthe engagement recess to engage the engagement surface of the pressuremember.
 13. The system of claim 12, wherein the instrument furthercomprises two front portions on which the engagement portion is formed,and wherein the front portions are movable towards one another forengaging the engagement portion with the engagement surface of thepressure member.
 14. The system of claim 12, wherein when the pressuremember is at the second position, the pressure exerted on the head isconfigured to lock the head relative to the receiving part.
 15. Thesystem of claim 12, wherein when the pressure member is at the firstposition, the pressure exerted on the head is less than the pressureexerted on the head when the pressure member is at the second position.16. The system of claim 12, wherein when the pressure member is at thefirst position, the pressure member does not exert pressure on the head.17. (canceled)
 18. A method for coupling a rod to a bone using a boneanchoring device comprising a bone anchor comprising a shank foranchoring in the bone and a head, a receiving part having a central axisand defining a channel transverse to the central axis for receiving arod, a coaxial passage, an accommodation space for accommodating thehead, and an engagement recess for engagement by an instrument, apressure member positionable at least partially in the accommodationspace, the pressure member comprising an expandable portion defining ahollow interior to accommodate and clamp the head and an engagementsurface for engagement by the instrument, wherein when the pressuremember is in the receiving part, the engagement surface of the pressuremember is accessible through the engagement recess of the receivingpart, and a locking member, the method comprising: anchoring the shankof the bone anchor to bone; adjusting an angular position of thereceiving part relative to the shank when the pressure member is in thereceiving part and the head is held in the pressure member; insertingthe rod in the channel; advancing the locking member in the channel tolock the rod relative to the receiving part and to move the pressureelement axially from a first position towards a second position toincrease a compression force on the expandable portion for clamping thehead to lock the angular position of the receiving part relative to theshank.
 19. The method of claim 18, further comprising attaching thereceiving part to the head of the bone anchor after anchoring the shankof the bone anchor to bone.
 20. (canceled)